The Tumor Microenvironment (TME) series to date is assembled here http://www.sugarconebiotech.com/?s=big+tent containing parts 1-3
I’m happy to point you to the most recent content, posted on Slideshare: http://www.slideshare.net/PaulDRennert/im-vacs-2015-rennert-v2
In this deck I review the challenges of the TME particularly with reference to Pancreatic and Ovarian cancers. A few targets are shown below.
Feedback most welcome.
Some thoughts to fill the space between AACR and ASCO (and the attendant frenzied biopharma/biotech IO deals).
Classical immune responses are composed of both innate and adaptive arms that coordinate to drive productive immunity, immunological expansion, persistence and resolution, and in some cases, immunological memory. The differences depend on the “quality” of the immune response, in the sense that the immunity is influenced by different cell types, cytokines, growth factors and other mediators, all of which utilize diverse intracellular signaling cascades to (usually) coordinate and control the immune response. Examples of dysregulated immune responses include autoimmunity, chronic inflammation, and ineffective immunity. The latter underlies the failure of the immune system to identify and destroy tumor cells.
Let’s look at an immune response as seen by an immunologist, in this case to a viral infection:
Of note are the wide variety of cell types involved, a requirement for MHC class I and II responses, the presence of antibodies, the potential role of the complement cascade, direct lysis by NK cells, and the potentially complex roles played by macrophages and other myeloid cells.
In the immune checkpoint field we have seen the impact of very specific signals on the ability of the T cell immune response to remain productive. Thus, the protein CTLA4 serves to blunt de novo responses to (in this case) tumor antigens, while the protein PD-1 serves to halt ongoing immune responses by restricting B cell expansion in the secondary lymphoid organs (spleen, lymph nodes and Peyer’s Patches) and by restricting T cell activity at the site of the immune response, thus, in the tumor itself. Approved and late stage drugs in the immune checkpoint space are those that target the CTLA4 and PD-1 pathways, as has been reviewed ad nauseum. Since CTLA4 and PD-1 block T cell-mediated immune responses at different stages it is not surprising that they have additive or synergistic activity when both are targeted. Immune checkpoint combinations have been extensively reviewed as well.
We’ll not review those subjects again today.
If we step back from those approved drugs and look at other pathways, it is helpful to look for hints that we can reset a productive immune response by reengaging the innate and adaptive immune systems, perhaps by targeting the diverse cell types and/or pathways alluded to above.
One source of productive intelligence comes from the immune checkpoint field itself, and its’ never-ending quest to uncover new pathways that control immune responses. Indeed, entire companies are built on the promise of yet to be appreciated signals that modify immunity: Compugen may be the best known of these. It is fair to say however that we remain unclear how best to use the portfolio of checkpoint modulators we already have in hand, so perhaps we can look for hints there to start.
New targets to sift through include the activating TNF receptor (TNFR) family proteins, notably 4-1BB, OX40, and GITR; also CD40, CD27, TNFRSF25, HVEM and others. As discussed in earlier posts this is a tricky field, and antibodies to these receptors have to be made just so, otherwise they will have the capacity to signal aberrantly either because the bind to the wrong epitope, or they mediate inappropriate Fc-receptor engagement (more on FcRs later). At Biogen we showed many years ago that “fiddling” with the properties of anti-TNFR antibodies can profoundly alter their activity, and using simplistic screens of “agonist” activity often led to drug development disaster. Other groups (Immunex, Amgen, Zymogenetics, etc) made very similar findings. Careful work is now being done in the labs of companies who have taken the time to learn such lessons, including Amgen and Roche/Genentech, but also BioNovion in Amsterdam (the step-child of Organon, the company the originally created pembrolizumab), Enumeral in Cambridge US, Pelican Therapeutics, and perhaps Celldex and GITR Inc (I’ve not studied their signaling data). Of note, GITR Inc has been quietly advancing it’s agonist anti-GITR antibody in Phase 1, having recently completed their 8th dose cohort without any signs of toxicity. Of course this won’t mean much unless they see efficacy, but that will come in the expansion cohort and in Phase 2 trials. GITR is a popular target, with a new program out of Wayne Marasco’s lab at the Dana Farber Cancer Institute licensed to Coronado and Tg Therapeutics. There are many more programs remaining in stealth for now.
More worrisome are some of the legacy antibodies that made it into the clinic at pharma companies, as the mechanisms of action of some of these agonist antibodies are perhaps less well understood. But lets for the sake of argument assume that a correctly made anti-TNFR agonist antibody panel is at hand, where would we start, and why? One obvious issue we confront is that the functions of many of these receptors overlap, while the kinetics of their expression may differ. So I’d start by creating a product profile, and work backward from there.
An ideal TNFR target would complement the immune checkpoint inhibitors, an anti-CTLA4 antibody or a PD-1 pathway antagonist, and also broaden the immune response, because, as stated above, the immune system has multiple arms and systems, and we want the most productive response to the tumor that we can generate. While cogent arguments can be made for all of the targets mentioned, at the moment 4-1BB stands as a clear frontrunner for our attention.
4-1BB is an activating receptor for not only T cells but also NK cells, and in this regard the target provides us with an opportunity to recruit NK cells to the immune response. Of note, it has been demonstrated by Ron Levy and Holbrook Khort at Stanford that engagement of activating Fc receptors on NK cells upregulates 4-1BB expression on those cells. This gives us a hint of how to productively combine antibody therapy with anti-4-1BB agonism. Stanford is already conducting such trials. Furthermore we can look to the adjacent field of CAR T therapeutics and find that CAR T constructs containing 4-1BB signaling motifs (that will engage the relevant signaling pathway) confer upon those CAR T cells persistence, longevity and T cell memory – that jewel in the crown of anti-tumor immunity that can promise a cure. 4-1BB-containing CAR T constructs developed at the University of Pennsylvania by Carl June and colleagues are the backbone of the Novartis CAR T platform. It is a stretch to claim that the artificial CAR T construct will predict similar activity for an appropriately engineered anti-4-1BB agonist antibody, but it is suggestive enough to give us some hope that we may see the innate immune system (via NK cells) and an adaptive memory immune response (via activated T cells) both engaged in controlling a tumor. Pfizer and Bristol Myers Squibb have the most advanced anti-4-1BB agonist antibody programs; we’ll see if these are indeed best-in-class therapeutics as other programs advance.
Agonism of OX40, GITR, CD27, TNFRSF25 and HVEM will also activate T cells, and some careful work has been done by Taylor Schreiber at Pelican to rank order the impact of these receptors of CD8+ T cell memory (the kind we want to attack tumors). In these studies TNFRSF25 clearly is critical to support CD8 T cell recall responses, and may provide yet another means of inducing immune memory in the tumor setting. Similar claims have been made for OX40 and CD27. Jedd Wolchok and colleagues recently reviewed the field for Clinical Cancer Research if you wish to read further.
Looking again beyond T cells another very intriguing candidate TNFR is CD40. This activating receptor is expressed on B cells, dendritic cells, macrophages and other cell types involved in immune responses – it’s ligand (CD40L) is normally expressed on activated T cells. Roche/Genentech and Pfizer have clinical stage agonist anti-CD40 programs in their immuno-oncology portfolios. Agonist anti-CD40 antibodies would be expected to activated macrophages and dendritic cells, thus increasing the expression of MHC molecules, costimulatory proteins (e.g. B7-1 and B7-2) and adhesion proteins like VCAM-1 and ICAM-1 that facilitate cell:cell interactions and promote robust immune responses.
I mentioned above that interaction of antibodies with Fc receptors modulates immune cell activity. In the case of anti-CD40 antibodies, Pfizer and Roche have made IgG2 isotype antibodies, meaning they will have only weak interaction with FcRs and will not activate the complement cascade. Thus all of the activity of the antibody should be mediated by it’s binding to CD40. Two other agonist anti-CD40 antibodies in development are weaker agonists, although it is unclear why this is so; much remains to be learned regarding the ideal epitope(s) to target and the best possible FcR engagement on human cells. Robert Vonderheide and Martin Glennie tackled this subject in a nice review in Clinical Cancer Research in 2013 and Ross Stewart from Medimmune did likewise for the Journal of ImmunoTherapy of Cancer, so I won’t go on about it here except to say that it has been hypothesized that crosslinking via FcgRIIb mediates agonist activity (in the mouse). Vonderheide has also shown that anti-CD40 antibodies can synergize with chemotherapy, likely due to the stimulation of macrophages and dendritic cells in the presence of tumor antigens. Synergy with anti-CTLA4 has been demonstrated in preclinical models.
One of the more interesting CD40 agonist antibodies recently developed comes from Alligator Biosciences of Lund, Sweden. This antibody, ADC-1013, is beautifully characterized in their published work and various posters, including selection for picomolar affinity and activity at the low pH characteristic of the tumor microenvironment (see work by Thomas Tötterman, Peter Ellmark and colleagues). In conversation the Alligator scientists have stated that the antibody signals canonically, i.e. through the expected NF-kB signaling cascade. That would be a physiologic signal and a good sign indeed that the antibody was selected appropriately. Not surprisingly, this company is in discussion with biopharma/biotech companies about partnering the program.
Given the impact of various antibody/FcR engagement on the activity of antibodies, it is worth a quick mention that Roghanian et al have just published a paper in Cancer Cell showing that antibodies designed to block the inhibitory FcR, FcgRIIB, enhance the activity of depleting antibodies such as rituximab. Thus we again highlight the importance of this sometimes overlooked feature of antibody activity. Here is their graphical abstract:
The idea is that engagement of the inhibitory FcR reduces the effectiveness of the (in this case) depleting antibody.
Ok, moving on.
Not all signaling has to be canonical to be effective, and in the case of CD40 we see this when we again turn to CAR T cells. Just to be clear, T cells do not normally express CD40, and so it is somewhat unusual to see a CAR T construct containing CD3 (that’s normal) but also CD40. We might guess that there is a novel patent strategy at work here by Bellicum, the company that is developing the CAR construct. The stated goal of having a CD40 intracellular domain is precisely to recruit NF-kB, as we just discussed for 4-1BB. Furthermore, the Bellicum CAR T construct contains a signaling domain from MYD88, and signaling molecule downstream of innate immune receptors such as the TLRs that signal via IRAK1 and IRAK4 to trigger downstream signaling via NF-kB and other pathways.
Here is Bellicum’s cartoon:
If we look through Bellicum’s presentations (see their website) we see that they claim increased T cell proliferation, cytokine secretion, persistence, and the development of long-term memory T cells. That’s a long detour around 4-1BB but appears very effective.
The impact of innate immune signaling via typical TLR-triggered cascades brings us to the world of pattern-recognition receptors, and an area of research explored extensively by use of TLR agonists in tumor therapy. Perhaps the most notable recent entrant in this field is the protein STING. This pathway of innate immune response led to adaptive T cell responses in a manner dependent on type I interferons, which are innate immune system cytokines. STING signals through IRF3 and TBK1, not MYD88, so it is a parallel innate response pathway. Much of the work has come out of a multi-lab effort at the University of Chicago and has stimulated great interest in a therapeutic that might be induce T cell priming and also engage innate immunity. STING agonists have been identified by the University of Chicago, Aduro Biotech, Tekmira and others; the Aduro program is already partnered with Novartis. They published very interesting data on a STING agonist formulated as a vaccine in Science Translational Medicine on April 15th (2 weeks ago). Let’s remember however that we spent several decades waiting for TLR agonists to become useful, so integration of these novel pathways may take a bit of time.
This emerging mass of data suggest that the best combinations will not necessarily be those that combine T cell immune checkpoints (anti-CTLA4 + anti-PD-1 + anti-XYZ) but rather those that combine modulators of distinct arms of the immune system. Recent moves by biopharma to secure various mediators of innate immunity (see Innate Pharma’s recent deals) and mediators of the immunosuppressive tumor microenvironment (see the IDO deals and the interest in Halozyme’s enzymatic approach) suggest that biopharma and biotech strategists are thinking along the same lines.
Two papers out this week add to a pile of data addressing the role of neoantigens in tumor therapy. While these papers address tumor neoantigen “load” in the context of immune checkpoint therapy the results have implications for TIL therapeutics, TCR therapeutics and onco-vaccine development.
A really dramatic paper from diverse groups at the University of Pennsylvania and their collaborators, just published in Nature (link-1), explores the complex interplay of radiation therapy and anti-CTLA4 antibody therapy (ipilimumab, from BMS) in patients with stage IV metastatic melanoma (relapsed or previously untreated). In this Phase 1/2 clinical trial (NCT01497808) patients with multiple melanoma metastases received various doses of radiation therapy delivered to a single metastasis, termed the “index lesion”. They then received 4 doses of ipilimumab (3 mg/kg, i.v., once every 3 weeks) and non-irradiated lesions were evaluated within 2 months of the last dose.
Although the sample size reported is small (n=22) some interesting lessons emerged from the study. The response rate was low, and the progression free survival (PFS: 3.8 months) and overall survival (OS: 10.7 months) data bear this out. It appears that just shy of 40% of patients were still alive at ~30 months (see Figure 1c in the paper). It is too early to tell if there will be a “long-tail” effect going forward. In the original ipilimumab study a very small percentage of patients lived for a very long time, “pulling” the PFS and OS curves to the right. Regardless, most patients in this study did not respond and the questions posed in this paper are directed to the mechanisms of resistance.
The mouse B16-F10 melanoma model was used to model resistance. Mice with tumors were locally irradiated then treated with an anti-mouse-CTLA4 antibody, to mimic the clinical trial. Only 17% of the treated mice responded. Two predictors of response/non-response were elucidated: 1) the ratio of effector T cells (Teff) to regulatory T cells (Treg) and 2) a gene signature in the tumor cells that is dominated by the expression of PD-L1 and IFNgamma regulated genes. In short, if the melanoma cells are expressing PD-L1 and the tumor infiltrating lymphocyte (TIL) population is dominated by Tregs (which are PD-1+), then the radiation + anti-CTLA4 therapy failed.
To further subset TIL into active Teff versus non-responsive “exhausted” Teff, the authors used an expression profile of PD-1+/Eomes+ to identify exhausted Teff and PD-1+/Eomes+/Ki67+/GzmB+ for active Teff. Importantly, exhausted Teff could be reanimated upon treatment with PD-1 pathway antagonists: anti-PD-1 antibody or anti-PD-L1 antibody. This reanimation led to an improved CD8+ Teff/Treg ratio and led to tumor control in the majority of the mice (up to 80%) when the treatment consisted of irradiation plus anti-CTLA4 plus anti-PD-L1. Of note, radiation plus anti-PD-L1 did not achieve this effect; the triple therapy was required (see Figure 2d).
The striking conclusion is that upregulation of PD-L1 on tumor cells can subvert the effect of anti-CTLA4 antibody therapy, and this therefore qualifies as a mechanism of resistance.
What about the role of irradiation? In both the patients and the mouse model irradiation was local, not systemic. Further, this local irradiation was required to achieve complete responses in the mouse model. What is going on here? Irradiation was linked to a modest increase in TIL infiltration of melanoma tumors in the mouse model, but sequencing of the T cell receptors (TCR) revealed that there was an increase in the diversity of TCRs, meaning that more antigens were being recognized and responded to by TIL after irradiation. In this context then, anti-CTLA4 reduced the Treg population, anti-PD-L1 allowed CD8+ TIL expansion, and irradiation set the antigenic landscape for response.
Returning to the patients armed with this information from the mouse study, the authors find that low PD-L1 expression on the melanoma cells correlates with productive response to irradiation plus ipilimumab therapy, while PD-L1 high expressing tumors were associated with persistent T cell exhaustion. In addition, monitoring the state of the CD8+ T cell population (PD-1+/Eomes+ versus PD-1+/Eomes+/Ki67+/GzmB+) suggested that these phenotypes might be useful as peripheral blood biomarkers. The patient numbers are very small for this analysis however, which awaits further validation.
The conclusion: irradiation combined with ipilimumab plus anti-PD-L1 antibody therapy should be a productive therapeutic combination in PD-L1+ stage IV melanoma. Similar strategies may be beneficial in other solid tumor types. This is interesting news for companies developing anti-PD-L1 antibodies, including BMS-936559 (also from BMS), MPDL3280A (Roche/Genentech), MEDI4736 (AZN) and MSB0010718C (Merck Serono).
A second paper (link) bring our focus back to PD-1, in the context of non-small cell lung cancer (NSCLC). Using the anti-PD-1 antibody pembrolizumab (from Merck) a group from the Memorial Sloan-Kettering Cancer Center sought to determine correlates of response of NSCLC patients to anti-PD-1 therapy. Their findings again hone in on neoantigen load, as the best predictors of response were the non-synonymous mutational burden of tumors, including neoantigen burden and mutations in DNA repair pathways. What all this means is that mutations that change the amino acid sequence (thus, are non-synonymous) can produce neoantigens that can be recognized by CD8+ T cells; mutations in the DNA repair pathways increase the rate that such mutations go uncorrected by a cell.
The authors sequenced the exomes (expressed exons – these encode proteins) from tumors versus normal tissue, as a measure of non-synonymous mutational burden that could produce neoantigens. Patients were subsetted based on response: those with durable clinical benefit (DCB) and those with no durable benefit (NDB). High mutational burden was correlated with clinical efficacy: DCB patients averaged 302 such mutations, while NDB patients averaged 148; ORR, PFS and OS also tracked with mutational burden. In a validation cohorts the number of non-synonymous mutations was 244 (DCB) versus 125 (NDB).
Examination of the pattern of exome mutations across both cohorts was studied in an attempt to discern a pattern of response to pembrolizumab treatment. The mutational landscape was first refined using an algorithm that predicts neoepitopes that can be expressed in the context of each patients specific class I HLA repertoire – these are the molecules that bring antigens to cell surfaces and present them to T cells for recognition (I’m simplifying this process but that is the gist of it). The algorithm identified more potential neoepitopes in the DCB patient tumors than in the NDB cohort, more impressively, a dominant T cell epitope was identified in an individual patient using a high-throughput HLA multimer screen. At the start of therapy this T cell clone represented 0.005% of peripheral blood T cells, after therapy the population had risen 8-fold, to 0.04% of peripheral blood T cells. Note that most of this clone of T cell would be found in the tumor, not in circulation, so that 8-fold increase is impressive. The T cells were defined as activated CD8+ Teff cells by expression markers: CD45RA-/CCR7-/LAG3-. As in the first paper we discussed, it is useful that these markers of systemic response to immunotherapy treatment are being developed.
There is an interesting biology at work here. It is often noted that high mutational burden is associated with better outcome, for example to chemotherapy in ovarian cancer, and irrespective of therapy across different tumor types (link-2). This suggests that tumor neoepitopes are stimulating an ongoing immune response that is stifled by active immunosuppression, yet is still beneficial. Once unleashed by immune checkpoint blockade, the immune system can rapidly expand it’s efforts.
We recently reviewed the importance of neoantigens in anti-tumor therapy (link-3) although the focus then was on cellular therapeutics rather than on immune checkpoint modifiers such as anti-CTLA4 and anti-PD-1 or PD-L1 antibodies. We can mow add that our ability to track neoantigens and the immune response to neoantigens is opening new avenues for investigating immuno-oncology therapeutics and their efficacy.
BMY today announced that an open-label, randomized Phase 3 study (CheckMate-017; NCT0164200) evaluating Opdivo vs docetaxel in previously treated patients with advanced, squamous NSCLC was stopped early because an assessment concluded that the study met its endpoint, demonstrating superior overall survival in patients receiving Opdivo.
CheckMate-017 is a Phase 3, open-label, randomized study. Patients who had failed prior platinum doublet-based chemotherapy received either nivolumab 3 mg/kg intravenously every two weeks or docetaxel 75 mg/m2 intravenously every three weeks (N = 272, randomized).
The primary endpoint is overall survival. Secondary endpoints include objective response rate and progression free survival. The initial time frame was 38 months from enrollment. The trial opened in 2012 and was scheduled for primary outcome measurement in January 2016, so this halt is a year early. An association between PD-L1 expression and efficacy measures (ORR, OS PFS) will be explored post hoc.
| Arms | Assigned Interventions |
| Experimental: Arm A: Nivolumab
Nivolumab 3 mg/kg solution intravenously every 2 weeks until documented disease progression, discontinuation due to toxicity, withdrawal of consent or the study ends |
Biological: Nivolumab
Other Name: BMS-936558 |
| Experimental: Arm B: Docetaxel
Docetaxel 75 mg/m2 solution intravenously every 3 weeks until documented disease progression, discontinuation due to toxicity, withdrawal of consent or the study ends |
Drug: Docetaxel
Other Name: Taxotere® |
Key Inclusion Criteria:
Key Exclusion Criteria:
So stopping this trial early is great news. What can we anticipate in addition to the report of ORR, OS, PFS etc that we will likely get at ASCO? The answer lies in the details regarding the Checkmate-017 trial.
A few pointers:
1) there is no inclusion biomarker, ie., there is no specified use of PD-1 staining of biopsy tissue that puts patients into the trial. This is in line with the confusion surrounding use of PD-1 as a biomaker.
2) there is a requirement that pretreatment biopsy specimens be available, as these will be used retrospectively to associate response with expression of biomarkers, including PD-L1 (the PD-1 ligand). No doubt many other biomarkers will be explored.
3) if you have autoimmune disease or interstitial lung disease (a broad term) you are out of luck. So patients with RA, MS, IBD, lupus, and a whole host of other autoimmune diseases need not apply. If you have Type 1 Diabetes though, your good to go (which among other things reminds us just how damn puzzling T1D autoimmunity is).
4) you also cannot be immunosuppressed (corticosteroids) or have had prior treatment with with anti- PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, anti-CTLA-4 antibody (including ipilimumab), or docetaxel. This last one excludes patients who may have gotten docetaxel as second line therapy, which is a setting in which it is commonly used. This tells us that the risk of toxicity in patients is deemed too high.
5) the study halt, being based on efficacy, does not mention toxicity, so we’ll have to wait and see.
Now back to the reading list. In the context of biomarker investigation this story has some resonance:
Day 2 – Immunotherapy: back to those biomarkers of response
Genetic Evolution of T-cell Resistance in the Course of Melanoma Progression
Sucker et al 2014. Clin Cancer Res; 20(24); 6593–604
This interesting paper outlines a technique for tracking the evolution of immune resistance, an essential part of the so-called immune editing process, using in vitro analysis of patient-derived (PDX) samples.
Three consecutive melanoma lesions obtained within one year of developing stage IV disease were analyzed for their recognition by autologous T cells.
One skin and two lymph node metastases were initially analyzed for T-cell infiltration. Then, melanoma cell lines established from the respective lesions. T-cell–stimulatory capacity, expression of cell surface molecules involved in T-cell activation, and specific genetic alterations affecting the tumor–T-cell interactions were identified.
Sampled skin lesions were infiltrated by T cells. The T cell infiltrate was diminished in the lymph node metastatic samples which were found to be HLA class I–negative due to an inactivating mutation in one allele of the beta-2-microglobulin (B2M) gene and concomitant loss of the other allele by a deletion on chromosome 15q. This is an impressive response to avoid immune detection.
The study reveals a progressive loss in melanoma immunogenicity during metastasis. Screening tumors for this and other genetic alterations that cause acquired immune resistance will be clinically relevant in terms of predicting patient responses and designing combinatorial approaches to immunotherapy.
Day 2 – Immunotherapy: back to those tox issues: it’s hard to control ipilimumab-induced tox
In the trial above we noted two things: no current corticosteroid use and no prior ipilimumab. Turns out these don’t play well together either
http://clincancerres.aacrjournals.org/content/early/2014/12/23/1078-0432.CCR-14-2353.abstract
Min et el. 2014. Systemic high dose corticosteroid treatment does not improve the outcome of ipilimumab-related hypophysitis: a retrospective cohort study
Purpose To examine the onset and outcome of ipilimumab-related hypophysitis and the response to treatment with systemic high dose corticosteroids. Patient and Methods Twenty-five patients who developed ipilimumab-related hypophysitis were analyzed for the incidence, time to onset, time to resolution, frequency of resolution, and the effect of systemic high-dose corticosteroids on clinical outcome. To calculate the incidence, the total number (187) of patients with metastatic melanoma treated with ipilimumab at Dana-Farber Cancer Institute (DFCI) was retrieved from the DFCI oncology database. Comparisons between corticosteroid treatment groups were performed using Fisher’s exact test. The distributions of overall survival were based on the method of Kaplan-Meier. Results The overall incidence of ipilimumab-related hypophysitis was 13%, with a higher rate in males (16.1%) than females (8.7%). The median time to onset of hypophysitis after initiation of ipilimumab treatment was 9 weeks (range: 5-36 weeks). Resolution of pituitary enlargement, secondary adrenal insufficiency, secondary hypothyroidism, male secondary hypogonadism, and hyponatremia occurred in 73%, 0%, 64%, 45%, and 92% of patients, respectively. Systemic high dose corticosteroid treatment did not improve the outcome of hypophysitis as measured by resolution frequency and time to resolution. One-year overall survival in the cohort of patients was 83%, and while slightly higher in patients who did not receive high dose corticosteroids, there was no statistically significant difference between treatment arms. Conclusion Systemic high dose corticosteroid therapy in patients with ipilimumab-related hypophysitis may not be indicated. Instead, supportive treatment of hypophysitis-related hormone deficiencies with the corresponding hormone replacement should be given.
Bristol-Myers Squibb (BMS) has quietly changed the protocol of clinical trial NCT01592370. This Phase 1 clinical trial has evolved from a nivolumab (anti-PD-1) study in hematological malignancies (5/4/14) to include ipilimumab (anti-CTLA4) with nivolumab (4/8/14) to now include nivolumab, ipilimumab and lirilumab (anti-KIR) as of 10/30/14. The changes were noted on Twitter (where else?) by several biotech experts who posted this screen shot:
The striking thing to notice is the addition of lirilumab across the board.
The clinical trial includes the following indications/inclusion criteria:
The trial covers Non-Hodgkin Lymphomas (NHL), Hodgkin Lymphoma (HL), Multiple Myeloma (MM), Acute Myelogenous Leukemia (AML), a subset of Chronic Myelogenous Leukemia (CML) and other hematologic malignancies. The requirement for biopsy tissue is to support biomarker analyses.
Lirilumab is an antibody developed by Innate Pharma (IPH.PA) that binds to the KIR2DL1, -2, and -3 receptors and prevents them from binding to HLA-C. HLA-C is a B2-microglobulin bound MHC family member with antigen presenting function. As an ancient system of antigen presentation, HLA-C is expressed on virtually all cell types. Binding of HLA-C to KIR2DL isoforms induces an inhibitory signal that prevents NK cells from engaging in cytotoxic control of tumors. By preventing KIR-mediated suppression of NK cells, lirilumab increases NK cell–mediated killing of HLA- C+ tumor cells.
Lirilumab showed signs of clinical activity in a Phase 1 trial and acceptable toxicity was observed (Vey et al. 2012. Blood 120: 4317, Vey et al. 2013. Blood. 122: 21, abstracts). A Phase II study of lirilumab in AML is in progress and combination Phase 1 trials of lirilumab in combination with ipilimumab and nivolumab for a variety of tumor types have begun. Lirilumab is also being tested in combination with the depleting antibody elotuzumab (anti-CS1) in refractory MM. The lirilumab-titled trials are listed below:
So what to make of all this activity? One reasonable conclusion is that enough data from interim analyses of the AML trials has come in to convince BMS to double-down on the partnership with IPH and move lirilumab forward aggressively. The breadth of indications is impressive. A second, related, conclusion is that preliminary data on lirilumab’s clinical activity in AML is ready for presentation at the American Society of Hematologists (ASH) Conference in December. The abstracts from that conference will come out on November 6th, so we’ll see.
There is considerable interest in combining T cell directed immune checkpoint therapeutics with those that act on NK cells. Innate Pharma (IPH.PA) has additional programs of interest in the NK cell space, including an antibody that targets MICA, a negative regulator of NKG2D-mediated activation of NK cells and an antibody that targets NKG2A, an inhibitory receptor.
The focus of this company on NK cell biology is impressive and may finally drive strong valuation. Innate has some very vocal supporters, but many investors seem reluctant to back this company. One reason perhaps is that it trades in Europe and liquidity of the corresponding US shares (OTC:IPHYF) is low. Another reason is perhaps the relationship with Novo Nordisk, which owns about 15% of company equity. From the scientific perspective the company is innovative and exciting, and I would love to have someone explain the stock valuation issues. Innate raised significant capital earlier this year with a round led by Orbimed, Redmile, FMR and about a dozen other top tier investors. An early look at AML results for ASH, or perhaps at ASCO, and strong clinical data thereafter could make many retail and institutional investors happy.
stay tuned
Part 2 – The Border Wars.
One of the fascinating aspects of the toxicity of immune checkpoint therapeutics is that it is a lot of is triggered at the border between self and non-self, where non-self is everything that the immune system must encounter and sort through continuously. The sorting serves to identify pathogens and ignore non-pathogens among the myriad components of the microfauna and flora that inhabit these borders. The “sampling” of these ecosystems is continuous and highly reactive – one glass of unpurified water taken on foreign soil will teach you this lesson pretty quickly. When the immune system is unrestrained by blockade of CTLA4 and/or PD-1 it is not surprising that we see the breakdown of immune tolerance in these border zones.
There are three major surfaces where toxicity has been an issue: the skin, the gut mucosa, and the airspaces of the lung. Ipilimumab treatment can cause pretty intense inflammation of the skin, generally dismissed in the clinical trial literature as “rash”. In a pooled analysis of nearly 1500 patients enrolled in various ipilimumab clinical trials, 45% developed dermatological AEs considered drug related, and 2.6% (so 39 people) developed severe symptoms rating a grade 3-4 (where grade 5 is lethal) (see Tarhani, A. Scientifica 2013, Article ID 857519). A fair amount of the milder skin AEs can be ascribed to an anti-melan-A response, as this antigen is abundant in melanoma, the setting for the clinical development trials. In the Phase 3 registrational trials dermatologic AEs were reported in more than 40% of patients in the ipilimumab arms, and there were very severe AEs that cannot be ascribed to an anti-melan-A (i.e melanocyte) immune response. This is from Tarhani’s review of patients in the ipilimumab + gp100 (vaccine) and ipilimumab monotherapy arms having dermatological irAEs,
“of these, 2.1% and 1.5%, respectively, were grade 3 or higher … Severe, life threatening, or fatal immune-mediated dermatitis (Stevens- Johnson syndrome, toxic epidermal necrolysis, … full thickness dermal ulceration, or necrotic, bullous, or hemorrhagic manifestations; grade 3–5) occurred in 13 of 511 (2.5%) patients treated with ipilimumab. One patient (0.2%) died as a result of toxic epidermal necrolysis, and one additional patient required hospitalization for severe dermatitis… .”
That’s some rash. We note in passing that dermatologic AEs were see in a phase 2 trial of ipilimumab plus chemotherapy in non-small cell lung cancer (NSCLC) and so this is certainly not limited to the melanoma setting. PD-1 pathway antagonists also cause skin inflammation in both the melanoma and other settings, similarly suggesting that what we are seeing here are immune responses to antigenic stimulation that is normally immunologically inert. Nivolumab-induced dermatologic toxicity can be severe, but is less common than seen with ipilimumab therapy.
The issue of skin toxicity is well known clinically, and there are established treatment protocols requiring cessation of therapy and treatment with anti-inflammatories, usually steroids (i.e the REMS protocols). The gastrointestinal (GI, “gut”) AEs are also common, can arise suddenly, be resistant to therapy (corticosteroids, and rarely, anti-TNF antibody), and are of significant concern. Returning to the pooled analysis of ~1500 ipilimumab patients we see roughly half of the patients developing GI symptoms (this includes diarrhea). If we focus on grade 3/4 SAEs we have 10-12% of patients with GI disorders that include colitis, enterocolitis, intestinal perforations etc that can proceed to lethal septic complications. Of note, inflammatory infiltrates in the intestines include abundant T cells and neutrophils, showing that acute ongoing inflammation is occurring. GI toxicity is less common and less severe in nivolumab-treated patients, and this is true also of Merck’s anti-PD-1 antibody pembrolizumab and the anti-PD-L1 antibody MPDL3280A from Roche. Colitis is generally not a big issue, for example, GI SAEs are seen in less than 1% of nivolumab-treated patients. We might conclude here that other pathways are maintaining tolerance in the gut mucosa when the PD-1 pathway is blocked.
A different picture emerges when we consider AEs in the lung. Pulmonary toxicity is rare in the context of ipilimumab monotherapy, with only scattered case reports in the literature (see Voskens et al for a review of rare ipilimumab-induced AEs: link). Anti-PD-1 pathway therapeutics, particularly nivolumab, are associated with pneumonitis, which is inflammation of the lung tissues. In the monotherapy setting, both nivolumab and pembrolizumab causes pneumonitis in 3-4% of patients – the condition is generally mild and treatable. Of note this AE rate is consistent across indications (e.g. melanoma, renal cell). The anti-PD-L1 antibodies (Roche’s MPDL3280A and Astra Zeneca’s MEDI4736) have not been associated with pneumonitis to date, perhaps reflecting a unique profile. The recent data from the anti-PD-L1 antibody MEDI4736 trial in NSCLC presented a tolerable profile. While response rate was low, significant numbers of patients remained on therapy with stable disease (ASCO 2014, Abstract #3002).
More worrisome is the pneumonitis rate and severity in combination therapy particularly in the NSCLC setting where diminished lung function is already a concern (smokers with lung cancer can’t breathe). When nivolumab was combined with platinum-based chemotherapy in NSCLC the SAE rate jumped to 45%, with notable findings of grade 3/4 pneumonitis (7%) and acute renal failure (5%) (ASCO 2014, Abstract #8113). Nivolumab plus erlotinib was not associated with pneumonitis (ASCO 2014, Abstract #8022) but response rates were low as well suggesting that these therapies were not particularly additive. The combination of nivolumab with ipilimumab was most worrisome, with grade 3/4 pneumonitis (6%) now seen along with grade 3/4 SAEs of skin (4%), GI (16%) and others (16%) (ASCO 2014, Abstract #8023). Most problematic is that 35% of patients discontinued, and between 3 to 5 patients died due to drug related SAEs including respiratory failure (caused by severe colitis), epidermal necrolysis (in a patient with multiple SAEs) and pulmonary hemorrhage (pneumonitis). As indicated above, the anti-PD-L1 antibody MEDI4736 may better suited for combination therapy. A combo trial in NSCLS with anti-CTLA4 mAb tremelimumab is enrolling, so we’ll wait and see.
It’s fair at this point to take a step back and say “so what?” These are close to terminal patients with deadly cancers usually highly refractory to treatment, and we cannot expect a free ride. The unmet need is acute and urgent, and these therapeutics offer potential cures and increase in life expectancy – as shown very clearly in last weeks early termination of the Phase 3 trial of nivolumab versus dacarbazine due to the obvious overall survival advantage offered by nivolumab (see John Carroll’s story in Fierce Biotech here: link)
The problem is that the response rates we are seeing are generally low, the discontinuation rates high, and for anti-CTLA4 and anti-PD-1 therapeutics there is no clear consensus regarding the use of biomarkers to select patients most likely to respond. Therefore the actual percent penetrance of therapy in the patient cohorts becomes quite low. For those relatively few patients who respond well the outcomes can be sustained and robust. It is critical however to get these response rates up. The blockbuster combination of nivolumab plus ipilimumab in metastatic melanoma gives us a sense of what is possible, if the drugs are tolerable. It is also critical to understand how and why immune therapy can make subsequent therapy intolerable, as we’ve seen in case reports, or conversely, how and why prior therapies can cause such problems for patients going onto an immune therapeutic (see that Voskens review mentioned above). We’ve seen some the issues that can bedevil combinations in metastatic melanoma (with vemurafenib) and in renal cell carcinoma clinical trials (pazopanib) When we look at all of the combination clinical trials underway with these agents we have to wonder what surprises lay in store.
Part 3 – The Fifth Column.
The fifth column refers to enemies lurking within the boundaries of the state, in this case the human body. These are a mixed collection of AEs that can be difficult to understand. While we are used to see liver and kidney inflammation in the setting of cancer therapy, it remains a bit mysterious that immune checkpoint therapy can cause severe inflammatory responses in these organs, the most notable is probably the induction of hepatitis in patients treated with ipilimumab. Even weirder (for me anyway) are the endocrinopathies, headlined by pituitary inflammation, seen with both CTLA4 and PD-1 directed immunotherapies. Primary thyroid inflammation is also seen although less frequently. These are of course autoimmune targets in this setting, but the triggers are obscure, as is also almost always true in autoimmune disease. Somewhat remarkable is the emergence of a sometimes fatal but normally very rare condition known as autoimmune hypophysitis or lymphocytic hypophysitis, which is inflammation of the pituitary gland. Hypophysitis is a unique toxicity of immune checkpoint inhibitors, and has been been seen in patients treated with ipilimumab, tremelimumab, and nivolumab. Because the pituitary sits in the middle of the limbic hypothalamic-pituitary-adrenal axis effects on the thymus and adrenal gland are also noted, with adrenal insufficiency being a severe and life-threatening complication. It must be stressed that the frequency of this AE is stunningly high, reaching 17% in some trials, as the disease has been described only very rarely, with a good deal less than 1000 cases ever known prior to the introduction of immune checkpoint therapeutics.
So we won’t dwell on this, as clinicians now know what to watch for, and treatment paradigms have been developed. As mentioned earlier, treatment generally involves initiation of steroids to control to autoimmune response, and cessation of immune checkpoint therapy.
Let’s return to the consideration of combination therapy, which I think we all agree is essential if we are really to expand use of immune therapeutics in the treatment of these difficult cancers. Great hope has been placed in the combination of CTLA4 and PD-1 targeting agents with “safe” immune checkpoint modulators, notably the IDO-inhibitor from Incyte. We have very little information to date, but it is notable that the dose limiting toxicity in the first combination trial of ipilimumab and INCB024360 from Incyte (INCY) was liver damage as measured by ATL elevation. It may be that merely piling on ways of disrupting Treg activity will not help with the toxicity profile; in fact, one might make the prediction that this approach will make things worse in some settings.
We’ve remarked in passing on the apparently mild safety profile of the anti-PD-L1 inhibitors compared to the PD-1 inhibitors. This makes some sense, as the ligands are expressed by the target tumor cells, and this may be the main sink for the injected antibody, i.e. antibody may not be evenly bio-distributed but rather predominantly localized to the tumors. The concordance of anti-PD-L1 antibody activity with tumor PD-L1 expression is consistent with a direct and localized effect. The fact that there is less consistent concordance of anti-PD-1 antibody activity with PD-1 expression by tumor-infiltrating T cells suggests less specificity in the induced immune response, and this may be why we see autoimmune toxicity in the nivolumab setting. As CTLA-4 is exclusively T cell expressed, the same seems to hold true for anti-CTLA4 antibody therapy. So combining these may not be the most ideal way forward.
We will discuss alternative approaches next time, but first there is some new data on novel immune checkpoint therapies to consider. These are the TNF receptor superfamily proteins that we discussed last month (link): 4-1BB, CD27, OX40 and GITR. There is admittedly very little data to date. Pfizer’s (PFE) anti-4-1BB antibody PF-05082566 reached a safe dose in Phase 1 without undue toxicity signals (ASCO 2014, Abstract #3007). Pfizer disclosed combination trials with rituximab in Non-Hodgkin Lymphoma (NHL) and pembrolizumab (anti-PD-1). The BMY antibody urelumab was tolerated through its’ dose escalation cohorts, and ex vivo analysis showed activation of CD8+ T cells and NK cells (ASCO 2014, Abstract #3017). The Celldex anti-CD27 mAb also has demonstrated safe dose escalation, although to date without signs of clinical activity (ASCO 2014, Abstracts #3024 and #3027). Celldex (CLDX) claims planned studies in combination with nivolumab, ipilimumab, and the targeted therapeutics darafenib and trametinib.
As we discussed in an earlier post, 4-1BB, CD27, OX40 and GITR are evolutionarily closely related receptors. Biomarker studies such as the one performed in the urelumab trial will be essential in understanding how these immune stimulatory pathways will differentiate clinically and which will be safe in combination settings. We’ve reviewed the biology of this superfamily recently (see these posts) so won’t do so again until we get some more clinical data.
Next we will introduce some novel targets in the TNF receptor superfamily, revisit some apoptotic pathway “influencers”, and will swing back around to PD-1 and PD-L1 in some other solid tumor settings (not necessarily in that order).
stay tuned.
As we watch the clinical development of PD-1 pathway inhibitors we are struck by the ability of this approach to produce clinical efficacy in diverse cancers. Here we will briefly run through the rest of the landscape, starting with non-small cell lung cancer (NSCLC), then touching on metastatic renal cell carcinoma (RCC), glioblastoma (GBM), bladder cancer (UB), ovarian carcinoma and others. In many cases we are beginning to see the use of combination therapy, a setting that generally requires a careful look at toxicity. We’ll also look at the contentious issue of biomarker development for PD-1 and PD-L1 antagonists. The data are broken down into easy to understand bits, otherwise the whole thing is overwhelming.
The Emerging Role of PD-1 Pathway Inhibition in Lung Cancer
In the context of the often brutally aggressive tumors classified as the Non-Small-Cell Lung Cancers (NSCLC) progress is difficult and even incremental improvement in care is cause for celebration. Even so it was difficult to gather a consensus view of the clinical data being generated by the PD-1 pathway antibodies in NSCLC. In the melanoma setting (parts 1 and 2) our enthusiasm for PD-1 pathway inhibitors is driven by really terrific responses in some patients. The goal there is to improve the response rates while controlling toxicity. The clinicians argue, certainly with merit, that the responses seen justify the occasionally difficult toxicity. After all, all of their available therapies are limited by toxicity concerns, not only chemotherapy but also the small molecule targeted therapeutics. In this context, PD-1 directed therapies are well positioned.
It is not yet clear how these issues will play out in NSCLC. On the positive side, a subset of patients respond remarkably well to PD-1 pathway inhibition, and we may develop an understanding of how identify such patients. However, the overall response rates remain low, and impact on PFS and OS is small (see part 1 for a list of abbreviations). Complicating our understanding of the benefit of this class of therapeutics in NSCLC are three observations. The first observation is that tumor responses in this disease setting can be anomalous and may not be appropriately captured by standard RECIST tumor response criteria. The second observation is that severe toxicity can truly derail patients, and may even sensitize some patients to chronic toxicity that prevents application of other types of therapies. The third observation is that some targeted therapeutics for molecularly defined subsets of NSCLC patients are an attractive option to PD-1 directed therapeutics, and we don’t know yet if these can be combined.
The amount of data presented at ASCO14 was huge, and won’t try to cover it all.
There was a pretty dramatic response to the clinical trial data describing the utility of PD-1 pathway inhibitors in NSCLC. Bristol-Myers Squibb’s (NASDAQ: BMY) stock price dropped more than 6% from the start of ASCO on May 30th through the following week, and this on top of a long slide that started in March. Merck & Co (NYSE: MRK) stock jumped more than 2.5% at the same time. What was going on here? Let’s look at the estimated market sizes for three critical indications:
It is clear from the table that NSCLC is the largest patient population by more than 10-fold. It is also the case that NSCLC lacks the range of treatment options available to advanced melanoma and RCC patients. From the investor perspective then, NSCLC is a very big deal. Lets start there, and see how the emerging PD-1 pathway therapeutic class did in this setting.
Nivolumab anti-PD-1 antibody was studied in a number of clinical settings (ASCO14 abstracts #8024 and #8113). As monotherapy, nivo was generally well tolerated, and very effective for some patients. The ORR = 22% – 36% and a subset of patients had a durable response. Combining nivo with dual-platinum based chemotherapy increased the response rate but dramatically increased the SAEs, and in this early data did not appear to impact 1 year survival rates significantly. This table sums up some of the available data.
Some patients responded very well – these were typically patients that had a non-squamous cell phenotype and whose tumors expressed PD-L1 and were therefore actively shutting down T cell responses by binding PD-1 on T cells. This figure is from a poster presented by Scott Gettinger (ASCO14 Abstract #8024).
Tumor size is given on the Y-axis and duration is shown across the X-Axis, so for some responding patients the outcome is very good. In an effort to boost the effectiveness of immunotherapy for NSCLC, BMY ran a combination trial of nivo + ipi, as they had done previously in melanoma. They enrolled chemo-naive NSCLC patients, stratified by cell type into squamous or non-squamous groups, then gave these patients an induction regimen of nivo + ipi for 84 days (4 x 21 day cycles). The doses were either 1 + 3 mpk IV Q3W or 3 + 1 mpk IV Q3W, referring to the dose or nivo + ipi, respectively. Then the patients went onto a nivo maintenance schedule. The combination worked rather well, seeming to wipe out the disparity between the two cell types and overcoming some of the resistance seen in PD-1 tumors. Here are some illustrations of the data from Scott Antonio’s poster (ASCO14 Abstract #8023):
As you can see, a fair number of patients have a sustained decrease in tumor volume or a stable disease course (no change in tumor volume over time). That’s a very nice result. Now the bad news. This combination therapy was nasty, a toxic brew. Discontinuation rates averaged 35% across the treatment arms with AEs including pneumonitis, liver damage, colitis, autoimmune nephritis (kidney inflammation & fibrosis), pulmonary hemorrhage, endocrinopathy, neuropathy, etc. Six patients (12%) died. We note that only 3 fatalities were directly attributed to the study drugs, but no one felt comfortable with these results. BMY’s stock price promptly dropped. We won’t know if the reaction was justified until other dosing and combo regimens are tried, but investors found another home, and that was with the competing drugs from Merck and Astra Zeneca (NYSE: AZN).
Immediately striking were the results from an NSCLC trial with the anti-PD-1 antibody pembrolizumab as monotherapy. Patients were selected based on positive PD-L1 staining on > 1% of tumor cells and given 2 or 10 mpg pembro Q3W or 10 mpk Q2W (ASCO Abstract #8077). The response rate was 26% or more, and the SAE rate was low (4%) although 18% dropped out due to AEs of any grade. Responses were durable with more than half of responders still on treatment at the time of data lock. A couple of things to note: these were treatment-naive patients, so presenting early in disease course. Second this figure (from the presentation by Naiyer Rizvi, ASCO #8007) shows maximum responses (ie. best response) and would not capture rebounding tumor size.
As side note: the authors introduced an “immune response” criteria response rate because some patients would respond after having a new lesion appear (which would trigger the progressive disease (PD) score). Using these new criteria responses were even higher. We’ll see if these become more widely accepted.
AZN/Medimmune presented early expansion data on their anti-PD-L1 antibody, MEDI4736 (ASCO14 Abstract #3002 presented by Neil Segal) in advanced solid tumors. 84 patients with NSCLC were enrolled. The reported ORR was low but this was an accident of sampling as most patients had not gotten to their second screen yet and could not be scored as responders, per protocol. More impressively the vast majority of patients, across diverse tumor classes, remained on therapy.
While it will be critical to see this data updated, the early read is very encouraging. Not waiting, AZN has initiated a pivotal trial in NSCLC and also a combo trial with their own anti-CTLA4 antibody, tremelimumab. We should be cautiously optimistic that the combination of anti-PD-L1 antibody with anti-CTLA4 antibody will have fewer tox issues than the anti-PD-1 combination, as mild tox appears to be a common feature of targeting the ligand rather than the receptor.
At this point of development, nivo has run into some problems in the combination setting, pembro looks promising, and MEDI4736 also looks promising. It will be very interesting to follow these story lines as they mature.
OK, RCC and other tumor types next, stay tuned.
Other PD-1 pathway therapeutics in advanced melanoma therapy.
Yesterday we focused on nivolumab, particularly in combination with ipilimumab, for the treatment of advanced melanoma. There are competing PD-1 pathway inhibitors that have now reported out substantial trial data. See part 1 for a list of PD-1 pathway therapeutics in development. Much attention has gone to Merck’s pembrolizumab, formally called MK-3475. The activity of pembrolizumab in melanoma is very similar to that of nivolumab, so it’s worth taking a closer look at the characteristics of the antibodies. Included here is pidilizumab, another anti-PD-1 antibody, developed by CureTech.
Attributes of note include the different sources of the antibodies (fully human vs humanized murine antibody), different isotypes (IgG4 vs IgG1) and affinities ranging more than 200-fold from sub-100pM to 20nM. However, this is a small number of antibodies and it will be hard to discern how each of these attributes contributes to efficacy. Pembrolizumab closely resembles nivolumab except that the affinity for PD-1 is as much as 10 fold better. At the doses given it is difficult to know if this makes any difference, as drug levels may be saturating. We’d have to dig out target occupancy data from the trials to figure this out, but let’s look at the pembrolizumab results first, as it will become clear that this antibody has similar efficacy as nivolumab. How these therapeutics are being developed is different, as we’ll see.
The pembrolizumab (“pembro”) data reported at ASCO are from a huge Phase 1 clinical trial in advanced melanoma. Importantly, Merck made the strategic decision to stratify patients by prior exposure to the anti-CTLA4 antibody ipilimumab (“ipi”), from Bristol-Myers Squibb. This gave the company a jump on the field, allowing them to pursue FDA approval first for ipi-refractory patients. Due in part to the toxicity associated with ipi therapy, there are a lot of these patients. First, though, a brief look at the data, which has been widely reported. The data are compared to published data for nivolumab (“nivo”) treatment of ipi-naive advanced melanoma patients (http://jco.ascopubs.org/content/32/10/1020.long). A guide to the clinical abbreviations is included in part 1.
If we focus on the ipi-naive ORR and 1 year survival data I think we have to conclude that these drugs are pretty comparable, and we’ll wait for additional data before trying too hard to differentiate these. That data will have to come from longer duration of ongoing trials and various combination studies. It is clear from the monotherapy data is that for advanced melanoma patients, anti-PD-1 therapeutics offer a chance at extended benefit. If we look more closely however,we see that in the nivo trial referenced above, half of the responding patients stopped therapy for reasons other than disease progression, most likely dropping off study due to AEs. It is true that 3/4s of the nivo patients stopping therapy maintained a response, some for extended periods. In the pembro study, the SAE rate was 12% but only 4% of patients discontinued therapy as a result of AEs, so that’s good. The catch is that in order to move ORR higher than 40%, combination therapy may be needed. As we saw with the ipi/nivo combo, this comes with much higher toxicity and drop-out rates. Of course the hope is that moving to earlier line therapy will boost response rates with the same or less toxicity and that data will come with time. As an aside, the question of ORR is the reason we have basically ignored the anti-PD-1 antibody pidilizumab, which had a 5-6% ORR. The 1 year OS was similar to the other anti-PD-1 therapeutics, but with such a low ORR it’s hard to believe this therapeutic from Curetech will gain much traction.
Anti-PD-L1 antibodies constitute the second class of therapeutics targeting the PD-1 pathway. These are in early clinical development in multiple tumor types, and will be addressed later. PD-L1 is also important in the context of predicting response to therapy in melanoma, and the utility of this marker as well as PD-1 is the subject of considerable discussion. When the ORR is 40%, it is helpful to select patients prospectively. We can take a close look at one of the smaller cohort studies to get a good look at this. In a study of responsiveness to pembro, Richard Kefford et al (abstract #3005) used an analysis of PD-L1 expression to demonstrate a remarkable difference in clinical response between patients who had > 1% tumor PD-L1 expression versus those who were PD-L1 negative. Biopsy was required in the 2 months preceding the start of pembro therapy; tumor PD-L1 expression was assessed by immunohistochemical staining. Patients received pembro at either 10 mg/kg Q2W, 10 mg/kg Q3W or 2 mg/kg Q3W. With a median treatment time of 23 weeks and ≥13 months follow-up, ORR was 41%, median PFS was 31 weeks and median OS was not reached. The 1-year survival rate was 81%, so this was a terrific cohort within the larger pembro study, likely due to the higher doses used. PD-L1 expression was associated with improved ORR by (51% vs 6%), PFS (median 12 vs 3 months) and 1-year survival rate (84% vs 69%). Note that while there were no treatment-related deaths; 14% of patients experienced drug-related SAEs (grade 3/4) again reflecting the aggressive dosing schedule.
In the large trial of ipi-naive patients treated with nivo, PD-L1 positive tumor staining was associated with ORR, but only weakly with PFS and OS. Why the data are less robust than the Kefford study is unclear. What is abundantly clear however is that there were profound responses in patients scored as PD-L1 negative, as shown in this screen grab from Dr Weber’s Discussant review of the melanoma oral poster session:
These data suggest that caution should be exercised in the use of PD-L1 staining as a prognostic tool, and the search for better biomarkers of response continues.
We will revisit some of these issues as we move on to NSCLC, RCC, bladder, ovarian and solid tumors more generally.
Introduction
Anyone attending the immunotherapy sessions at ASCO earlier this month would have heard several distinct messages about PD-1 pathway inhibition in oncology. PD-1 appears to be a central control point for curtailing T cell responses in the peripheral tissues, similar to the role that CTLA4 plays in regulating initial T cell activation in secondary lymphoid organs such as the lymph nodes and spleen. Remarkable progress has been made in the 13 years since Gordon Freemen and colleagues first proposed in Nature Immunology that the PD-1 pathway was used by tumor cells as a shield against immune system attack (http://www.ncbi.nlm.nih.gov/pubmed/11224527).
It is clear that PD-1 pathway antagonists show tremendous promise in treating diverse cancers. Less clear is an understanding of why certain patients respond or don’t, what biomarkers might predict response, how to increase response rates, how to accurately measure response, and how to safely combine PD-1 pathway inhibition with other therapies.
Table 1 lists the PD-1 therapeutics in development (some of these therapeutics did not have updates at ASCO).
As the table demonstrates, the PD-1 pathway inhibitors are being developed in diverse tumor types. As late Phase 2 data and Phase 3 data are coming out we can begin to see the real promise of these drugs in clinical responses measured in large numbers of patients. The amount of data presented at ASCO was a bit overwhelming so to simplify the landscape we can address each tumor type individually, when possible. Some terms we will use are given in the table below.
Table 2 defines the RECIST1.1 clinical response parameters and their abbreviations.
To put these terms in perspective we can just consider that a meaningful clinical response is a measureable response to therapy (SD < PR < CR) that is durable and leads to an increase in PFS, which in turn allows a significant increase in OS. There are other terms used to describe clinical responses but these are the most common. We will start with some of the most recent data, and see where that takes us.
Part 1: Immune Checkpoint Combination Treatment of Melanoma
The very first trials of PD-1 pathway inhibitors began with the investigation of nivolumab in metastatic melanoma. As such, there was an impressive amount of progress reported and we now have mature data on different therapeutics. To set the stage, we can consider the benefit shown by nivolumab monotherapy compared to standard of care treatment protocols, and also to ipilimumab (brand name Vervoy) an anti-CTLA4 antibody, also from Bristol-Myers Squibb (BMY). Ipilimumab is approved for the treatment of metastatic melanoma based on Phase 3 clinical trial data in metastatic melanoma patients that had failed prior therapy (a chemotherapy regimen). The trial compared ipilimumab to a tumor vaccine targeting the melanoma antigen gp100. Ipilimumab treatment improved median OS to 10 months versus 6 months with the vaccine treatment (which was no better than standard of care). The 1 year survival rate was 45%. ORR however was low, just about 10%. Also, adverse events (AEs) were a problem, and included autoimmune manifestations (colitis, pituitary inflammation) and some treatment-related deaths (2% of patients). In a separate study of treatment-naive metastatic melanoma patients, ipilimumab therapy was associated with an OS = 11.2 months and a 1 year survival rate of 47%, falling to 21% by year 3. Patients were given ipilimumab or placebo plus chemotherapy (dacarbazine), and then moved to ipilimumab or placebo alone if there was a response measured or if the initial therapy caused toxicity. One consequence of this scheme was that AEs went up dramatically, with 38% of patients experiencing an immune related, grade 3 or 4 severe AE (SAE). We dwell on the anti-CTLA4 antibody ipilimumab because it is the benchmark for other immunotherapies such as nivolumab.
Nivolumab therapy for advanced melanoma has produced impressive data, with median OS = nearly 17 months, and 1 and 2-year survival rates of 62% and 43%. ORR was 33%. AEs were significant if less severe than those seen with ipilimumab. Grade 3-4 treatment-related AEs were seen in 22% of nivolumab-treated patients. Immune-related adverse events (all grades) were seen in 54% of treated patients, and included skin, GI and endocrine disorders. However only 5% of patients experienced immune-related SAEs of grade 3 or 4 and there were no drug-related deaths. These data from Topalian, Sznol et al. from John Hopkins University School of Medicine were presented at ASCO last year and published earlier this year (http://jco.ascopubs.org/content/early/2014/03/03/JCO.2013.53.0105.full.pdf).
So with that as our backdrop lets update the state of PD-1 pathway antagonism in melanoma. One of the obvious next steps in the development of immunotherapy is to combine treatments and we saw dramatic long-term data from the combination trial of ipilimumab plus nivolumab in advanced melanoma. Early trial results presented at ASCO last year introduced 4 cohorts of patients given different doses of nivolumab and ipilimumab in combination, with an ORR across all four cohorts of 40% and a 1 year survival rate of 82%. Median OS had not been reached. SAE rate across the 4 cohorts was 53%. This quickly gets complicated so let’s define the cohorts. Numbers are doses of nivolumab and ipilimumab, respectively, in mg/kg: Cohort 1 (0.3 + 3), Cohort 2 (1 + 3), Cohort 3 (3 + 1), Cohort 4 (3 + 3). No data were presented for Cohorts 6 and 7 so we’ll skip those. Cohort 8 is designed to mimic the dose schedule chosen for later clinical trials.
Note that after the induction phase, patients are moved onto maintenance therapy, as show below.
The slide is taken from the trial update presented at ASCO by Dr Sznol (Abstract #LBA9003). The data updates drove home several critical points. First, at the optimal dose rates of 1 + 3 and 3 + 1 the ORR ranged from 43-53%. The author’s introduce a new classification of clinical response to capture the observation that many patients are experiencing benefit while not strictly meeting RECIST1.1 criteria, this is termed “Aggregate Clinical Activity Rate” and reaches 81-83% in Cohorts 3 and 4 (note that Cohort 4 (3 + 3) was the maximum tolerated dose due to SAEs and will no longer be used). Perhaps more meaningfully, the percent of patients whose tumor burden was reduced by > 80% at 36 weeks was 42% across the cohorts. This is a remarkable number suggesting sustained clinical benefit. Indeed, in those patients who responded, the median DOR in Cohorts 1-3 plus Cohort 8 has not been reached. In Cohorts 1-3, 18/22 patients are still responding and 7 of those had discontinued therapy due to AEs (more on this below).
Dose cohorts were analyzed for impact on 1 and 2 year survival. In Cohorts 2-3 the 1 year OS = 94% and the 2 year OS = 88%. Most stunning of all was this data showing a median OS in Cohorts 1-3 of 40 months. Median OS in Cohort 3 (1 + 3) has not yet been reached.
These data are best-in-class for treating advanced melanoma, and place ipilimumab plus nivolumab at the forefront of therapeutic options for these patients. The one outstanding issue remains that of toxicity. 23% of patients had to discontinue therapy due to toxicity, and one patient died of complications resulting from treatment. While Dr Sznol repeatedly pointed out that the toxicities observed are controlled by standard interventions, the problem is that these standard interventions include cessation of therapy. We have already learned from the ipilizumab experience that responses to immune checkpoint inhibition can take time, and for those patients who have to stop treatment after 1 – 2 doses due to toxicity, time may not be kind. It will certainly be beneficial to reduce SAEs so that more patients can remain on therapy.
Tomorrow we’ll look at other PD-1 pathway therapeutics and combinations in melanoma before moving on to other tumor types.
The recent news that Merck will aggressively partner the anti-PD-1 program MK-3475 with competitors Pfizer and Amgen, and biotech Incyte, was a welcome recognition that the immunotherapy landscape is too vast and complex for most companies to handle alone. Companies that will succeed in this space over the long haul will position themselves to “sample” many assets and technologies, particularly in combination settings. Why? First, because many combination therapies will fail or be too toxic to use, second, therapeutic modalities will evolve rapidly or be replaced, and third, personalized oncology practice will fragment patient populations.
Merck’s anti-PD-1 antibody MK-3475 is an example of the first generation of immune checkpoint inhibitors, for which we have clinical data. Other first generation therapeutics are ipilimumab (Vervoytm) approved for the treatment of metastatic melanoma, and nivolumab, an anti-PD-1 antibody moving toward regulatory submission this year, both from Bristol Myers Squibb. There are other anti-CTLA4 and anti-PD-1 pathway antibodies in clinical development, just a bit behind, including antibodies to PD-L1 from Roche (RG7446) and Astra Zeneca (MEDI-4736) and to CTLA4 from Pfizer (tremelimumab). It is fair to say that Merck has generated intense buzz around the MK-3475 program, driven by excellent clinical data and an aggressive approval strategy.
If we look over the details of the Merck collaborations we see a convergence of technologies around combination therapy. The Merck/Amgen collaboration centers on developing the oncolytic vaccine T-Vec in combination with MK-3475. The therapeutic hypothesis is relatively straightforward. The immune response to vaccines built using tumor antigens is blunted, in part, because of the immunosuppressive signals induced by PD-L1 expression on tumor cells. So blocking PD-L1/PD-1 mediated immunosuppression may allow a more robust immune response to anti-tumor vaccination strategies. I’ll note here that Amgen recently reported Phase 3 results from their T-Vec trial in metastatic melanoma, hitting the primary clinical endpoint of durable response but just missing the secondary endpoint of improving patient overall survival, which is an endpoint that the immune checkpoint inhibitors do hit. So Amgen has clear motivation here to combine T-Vec with immune checkpoint inhibitors. In addition to the collaboration with Merck, Amgen also has a collaboration with Bristol-Myers Squibb to clinical evaluate the combination of ipilimumab and T-Vec in metastatic melanoma.
The collaboration between Merck and Incyte is also focused on disabling immunosuppressive signaling, in this case as mediated by inhibition of indoleamine 2,3-dioxygenase (IDO), a pathway that regulates T cell responses by depleting tryptophan from the local tumor environment. IDO also appears to regulate T cell activity in lymph nodes draining the tumor site. IDO inhibitors promote T cell effector function while reducing the immunosuppressive activity of T regulatory cells. Incyte’s IDO inhibitor INCB24360 is in Phase 2 clinical trials in metastatic melanoma and in ovarian cancer. In this case then we are considering the potential of dual immune checkpoint inhibition, blocking PD-1 and IDO simultaneously. Incyte already has a Phase 1/2 trial in metastatic melanoma of INCB24360 in combination with ipilimumab and a Phase 1 trial in late stage melanoma in combination with a tumor vaccine.
Merck’s MK-3474 collaboration with Pfizer is very interesting. A phase 1/2 combination trila with axitinib a VEGFR-selective multi-kinase inhibitor (Inlytatm), will be run in renal cell carcinoma. Axitinib is approved as second line therapy in kidney cancer, but the drug has limited potential as a long term therapy and has struggled to distinguish itself from the older multi-kinase inhibitor sorafenib (Nexavartm, from Bayer/Onyx). It is very hard to guess what such a trial will yield, but such combinations of targeted therapies (kinase inhibition in this case) and immune-checkpoint modulators will have to be tried. A recent example, combining ipilimumab and the BRAF inhibitor vemurafenib (Zelboraftm, from Roche) in metastatic melanoma induced unacceptable liver toxicity and was stopped after only four patients had received the combination. Ipilimumab and nivolumab have very different toxicity profiles, and attempts at different combinations are certainly warranted.
The collaboration between Merck and Pfizer also includes development of the combination of MK-3475 with Pfizer’s PF-05082566, an agonist anti-4-1BB antibody. 4-1BB is a potent immune stimulatory pathway that acts by boosting T cell activity. Of interest, PF-05082566 is already in a Phase 1 solid tumor (as monotherapy) and B cell lymphoma (as dual therapy, with Roche’s anti-CD20 mAb rituximab). Finally, Merck and Pfizer have an second agreement to investigate the combination of MK-3475 with palbociclib, a CDK4/6 inhibitor that recently showed encouraging data in advanced breast cancer, although without yet demonstrating an impact on overall survival. These types of combinations are designed to give that precise boost in efficacy, allowing at least some patients the benefit of long term responses that impact disease progression and survival.
Merck’s internal immunotherapy pipeline is thin but as we noted the other day they are beginning to target other pathways, in part via the Agenus/4-Antibody platform deal.
I titled this post “Risks, Assets and Innovation in Immunotherapy Pipelines” because Merck’s efforts around MK-3475 illustrate some clear themes in this space. One, already mentioned, is that going into this space solo is something no company, except perhaps Bristol Myers Squibb (BMY), can contemplate. Even BMY reached outside the company recently to license an anti-KIR antibody from Innate Pharma and to partner with Five Prime Therapeutics on antibody discovery. Why is BMY in such a dominant position? They were innovative (CTLA4 biology) and they have multiple assets including antibodies to CTLA4, PD-1, LAG-3, KIR, 4-1BB and PD-L1, with more on the way. Note that I’m not saying that BMY’s anti-PD-1 antibody nivolumab is better or worse than Merck’s MK-3475, nor do I much care which gets approval first, a race that lots of folks are watching. No one horse will win this field, which brings us back to assets and pipelines.
Beyond BMY, companies like Merck are aggressively partnering because as the immunotherapy field was developing they were less innovative, took fewer risks, and therefore have fewer assets in this space. Companies like Pfizer and Novartis that spent the last decade chasing one oncogenic mutation after another down the rabbit hole found themselves very quickly on the outside looking in. They are now buying and partnering to build portfolios.
And that’s just fine; further, this should be a “pull” environment that motivates the biotech community to generate an abundance of assets. Small biotechs are classically trying to be innovative (to differentiate), take risks (to return dollars on investment) and therefore develop new assets. These are the fundamentals that should drive further expansion of the immunotherapy portfolio across the industry. So how is biotech doing in this new landscape? It is a mixed picture. There is a dearth of new first and second-generation immunotherapeutics, a space that I believe should be asset-rich. This is why Five Prime, 4-Antibody and Costim were all able to do healthy deals relatively early in their development – there is just not a lot of competition.
What happened? Why aren’t there half a dozen anti-PD-1 and anti-PD-L1 antibodies looking for partners, or a dozen agonist antibodies to 4-1BB, OX40, and GITR, and multiple inhibitors of TIM-3 and Lag3? I think this is a case of history repeating itself. After remicade and etanercept were approved, biotechs ran from the TNF inhibitor space, all believing, incorrectly, that they would never be able to compete. Seven TNF inhibitors later, this class still dominates the rheumatoid arthritis market. I wonder if small biotechs are reluctant to follow-on with additional antibodies to the first and second-generation immune checkpoint space because they think they are “too late” – in other words, the value proposition is too risky. If so, I believe they are wrong. The appetite is clearly there, with large biopharma and antibody engineering companies hungry for assets to pull into their pipelines.
Instead, many small biotechs are trying to stay well ahead on the innovation curve, chasing new targets. The problem, as always, is that no one wants to fund that work, because the risk is very high. So the answer is to try to balance innovation and risk in order to create assets that investors will fund. Its a tricky proposition, but essential to biotech’s ability to continue contributing to immunotherapy, and driving value creation. That said, there are some terrific innovative programs out there, in the hands of focused and smart small companies. In the meantime, there are more companies seeking validated assets than there are good programs developing these assets. SugarCone Biotech spends a lot of time building strategic programs for biotechs and a lot of time matching quality assets with partners and investors, so we see this first- hand.
Why else would we need more assets? Straight off, the existing immune checkpoint antibodies ipilimumab and nivolumab induce some terrific responses, but the response rates could be improved. Second, development of the existing combination therapy of ipilimumab and nivolumab has been tricky, with excellent efficacy but troubling toxicity. Note here that BMY can tinker with the dosage and dose schedule of each agent in such combination trials, because they own them both. Less asset-rich companies seeking to develop combination therapy strategies either have to partner their programs (Merck, as discussed here, but AbbVie might be another good example), or acquire everything they can afford (Novartis).
We’ll be watching closely.
stay tuned.